key: cord-0801370-en9hklwa
authors: Araji, Sarah; Reeve, Kristin E.; Wallace, Kedra; Morris, Rachael
title: 924 Is the HScore predictive of mortality in obstetric patients admitted to the ICU with COVID-19?
date: 2021-02-28
journal: American Journal of Obstetrics and Gynecology
DOI: 10.1016/j.ajog.2020.12.949
sha: 4207590cb5ea04e8eb46daffaf4ba9f3f3475272
doc_id: 801370
cord_uid: en9hklwa

nan

OBJECTIVE: Expert consensus is that physical exam-indicated cerclage (PEIC) is beneficial in prolonging pregnancy and decreasing perinatal mortality. Maternal risks of PEIC are rarely reported but can include intra-amniotic infection (IAI) and even sepsis with intensive care unit admission. The objective of this study is to describe the risks of maternal morbidity after physical exam-indicated cerclage. STUDY DESIGN: This was a retrospective cohort of pregnancies at 15.0 to 24.0 weeks gestation with a diagnosis of cervical insufficiency who underwent PEIC from October 1, 2015 to December 31, 2019. Patients with incomplete follow up were excluded. Amniocentesis was not routinely performed, and antibiotics and indomethacin were administered at the discretion of the clinician. The outcome of interest was composite maternal morbidity (CMM) which included chorioamnionitis, endomyometritis, surgical site infection, reoperation after delivery, postpartum hemorrhage, blood transfusion, hospital readmission, hysterectomy, intensive care unit (ICU) admission, or death. Patients were divided into ¼2cm cervical dilation at the time of cerclage and outcomes compared. Chi-squared, Fisher's exact and Wilcoxon tests were used for comparisons and p<0.05 was considered statistically significant. RESULTS: 113 patients underwent PEIC during the study period. 86 (76%) with complete follow-up data were included. Antibiotics were used in 31 (36%) and indomethacin in 56 (65%), both greater for patients with >¼2cm cervical dilation (p's<0.01). Overall, CMM occurred in 21 patients (24% , Table) . CMM was greater for patients with >¼2cm dilation (p¼0.02). Latency from cerclage placement to delivery was negatively associated with CMM (p<0.01, Figure) . CONCLUSION: Judicious use of PEIC is important because a substantial proportion of these patients experience morbidity, likely due to underlying subclinical infection. The morbidities can be serious, with a hysterectomy and ICU admission in this series. Amniocentesis for diagnosis of IAI prior to PEIC should be studied further and considered given these risks.

924 Is the HScore predictive of mortality in obstetric patients admitted to the ICU with COVID-19? OBJECTIVE: With the continuing spread of the COVID-19 pandemic, much attention has been focused on the role of cytokine storm in patients most severely affected by the virus. The HScore was developed and validated for the diagnosis of secondary hemophagocytic lymphohistiocytosis (sHLH), a condition that shares a similar cytokine profile to severe COVID-19. However, no studies have been published that specifically look at the HScore in an obstetric COVID-19 population. Our goal for this study was to evaluate the utility of the HScore in predicting mortality in obstetric patients admitted to the intensive care unit (ICU) with COVID-19. STUDY DESIGN: Data were collected from women enrolled in a prospective observational study to assess the impact of COVID-19 on pregnancy. HScores for women admitted to the COVID-19 ICU between April 2020 and September 2020 were calculated. Student's t test and Fisher's exact test were used to assess data, p<0.05 was considered significant. Data are expressed as meanAEstandard deviation. RESULTS: 15 women qualified for this study with a median age of 28 years (range 19-42) and a mean BMI of 36 kg/m2 (range 21-64). Seventy three percent of these women were Black, 13.3% were American Indian, 6.6% were Hispanic and 6.6% were White. The mean HScore was 80.3AE8.3. Sixty percent of women had HScores less than 90. Mortality was not associated with HScores90 were mortalities. The remaining 4 patients with HScore>90 were discharged from the hospital. Interestingly, the two mortalities did not have the highest HScores in our cohort. CONCLUSION: Our results show that an elevated HScore was not useful for predicting mortality in obstetric patients with COVID-19 who were admitted to the ICU. However, HScore<90 was associated with survival in our patient population. Further research is needed to evaluate the effects of the COVID-19 cytokine storm in the obstetric population. Application of the Hscore in the obstetric population may be misleading given the normal physiologic laboratory changes of pregnancy.

925 Implementation of postpartum home blood pressure monitoring to reduce readmissions for hypertensive disorders of pregnancy Bethany Sabol 1 , Megan C. Oakes 2 , Dani Turnbull 2 , Nandini Raghuraman 2 , Jeannie Kelly 2 , Ebony B. Carter 2 , Molly J. Stout 3 , Roxane M. Rampersad 4 OBJECTIVE: Postpartum readmissions due to hypertensive disorders of pregnancy (HDP) comprise over 50% of our monthly obstetrical readmissions. We sought to implement an evidence-based postpartum home blood pressure monitoring system to reduce postpartum readmissions due to HDP. STUDY DESIGN: This quality improvement initiative enrolled postpartum women with HDP or chronic hypertension. To enroll they also had to be English speaking and have access to text messaging. We utilized University of Pennsylvania's Heart Safe Motherhood automated text-based platform which allowed providers to remotely monitor blood pressure and titrate medications for patients from discharge through 14 days post discharge. Our primary outcome measure was postpartum readmission due to HDP. We aimed to reduce preventable readmission rates due to HDP by 50%. RESULTS: In the four months following implementation (April 1e July 31, 2020) our overall 30-day readmission rate decreased from a baseline of 2.4% prior to implementation to 1.8% following implementation. The percentage of readmissions secondary to hypertension decreased by 24% between the two study timepoints (62.2% pre-implementation vs. 38.1% post-implementation, p¼0.08; Figure 1 ). The majority of women readmitted were participating in home blood pressure monitoring at the time of their readmission (N¼ 13; 62%) and women with hypertensive disorders of pregnancy were most commonly readmitted due to worsening disease, such as gestational hypertension with subsequent development of preeclampsia with severe features (N¼6; 75%). CONCLUSION: During the four months following implementation of a home blood pressure monitoring system, postpartum readmissions due to HDP were reduced by over a third. Although not statistically significant, this has a clinically significant impact on both patient and system levels. Additionally, the majority of the women readmitted were participating in home blood pressure monitoring suggesting that heightened surveillance and improved postpartum communication may identify at risk women triaging them for more urgent evaluation.

STUDY DESIGN: Secondary analysis of a retrospective cohort study at a single academic hospital of singleton pregnancies delivered between 1/2015 e 10/2017 with !2 visits prior to the third trimester was performed. Data on RF and ASA utilization were extracted from a perinatal research database, electronic medical record (EMR) ICD-10 codes, and medication lists. Manual abstraction was done for a subset with chronic hypertension (cHTN) to assess missed over-thecounter (OTC) use of ASA. Relative risk (RR) of ASA utilization was calculated for each RF using ASA utilization in pregnancies in the same risk category (i.e. high, moderate) as referent. RESULTS: 5333 of 6755 (78.9%) pregnancies in the primary study were within the target time frame